What is the difference between a preoperative note and an H&P? Is there a time frame on when the pre-op or H&P are performed prior to surgery?
An H&P ("History & Physical") is more comprehensive than a preoperative note. At the time of the H&P, the patient's problem may be known, but the H&P is necessary in order to determine the course of treatment or if surgery is required. The H&P may be performed by the patient's referring physician or may be performed by the surgeon at the time of the patient's first visit. State regulations and facility policies vary with regard to the time period for an H&P. The Joint Committee on Accreditation of Healthcare Organizations ("JCAHO") standards and ASC accreditation groups require that the H&P be performed within thirty (30) days of the procedure.
The pre-op note is generally much more limited in scope and is performed immediately prior to the surgery (the day of the surgery or the day before). The note should indicate if there were any changes in the patient's health during the time period between the date of the H&P and the date of the surgery. The physician should review the previously completed H&P make a note that it was reviewed, note any changes in medications, patient's status, any medications the patient took the day of the surgery, etc. and perform a brief examination to ensure that the patient's health status is appropriate for the planned surgery.
Is it required to have one or both documented in the patient's chart prior to surgery?
If you are billing for the services, then you absolutely must have documentation of the services provided. From a risk management perspective, all services should be documented even if there is no charge for them (for example, post-operative follow-up visits during the global period). Medicare and many other payors follow the rule that if the service is not documented, the service was not performed. Since evaluation and management services are a component of most surgical CPT codes (with the exception of some minor procedures), payors, during an audit, expect to see the pre-op notes. Regulatory and licensure surveyors will expect both the H&P and the pre-op notes to be in the medical record.
Mary Beth Black, CPC
MMA does not provide legal, accounting, or tax advice. If you need assistance in these
areas, we recommend that you consult a qualified professional. In
addition, please note that a client relationship with MMA is not established
by the submission of a question to this forum or by the publishing of MMA's